提高紧急腹腔切除术的操作文档:系统审查和制定综合报告模板
Aiman Elamin1, Emma Walker1, Michael Sugrue2
1Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland.
World journal of emergency surgery : WJES
|December 1, 2023
概括
缺少紧急腹腔切除术的综合性操作报告. 开发了一个新的模板来改进外科手术文档,帮助数据分析,培训和研究,以获得更好的患者结果.
科学领域:
- 手术文档手术文档的手术文档.
- 医疗信息学医学信息学
- 患者安全 患者安全
背景情况:
- 当前的行动报告往往是叙事性的,难以解释.
- 这可能导致关键程序信息被遗漏.
- 紧急腹腔切除术 (EL) 需要标准化的文件.
研究的目的:
- 系统地审查综合性行动报告的可用性.
- 为紧急腹腔切除术开发一个综合性手术记录模板.
主要方法:
- 进行了PROSPERO注册的系统审查 (2012年1月至2022年12月).
- 搜索的数据库包括PubMed,Scopus和科学网.
- 排除了针对特定患者群体和审查类型的研究.
主要成果:
- 没有找到有关EL的综合性操作报告的相关发表文章.
- 开发了一个全面的111个领域的综合性操作记录模板.
- 模板包括人口统计,发现,干预和结果变量的字段,以及数字组件.
结论:
- 在紧急腹腔切除术的综合性手术报告中存在很大的差距.
- 开发的模板为清晰的外科手术文件提供了一个平台.
- 这可以增强数据分析,住院培训,研究和对患者结果的理解.
相关概念视频
01:17Flow Sheet
1.6K
Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
1.6K
01:26Methods of Documentation IV: Focus Charting
1.0K
Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
It typically involves three columns for recording information:
1.0K
01:24Data Reporting and Recording
4.7K
Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
4.7K
01:28Formats for Nursing Documentation
1.0K
Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
1.0K
01:26Guidelines for Nursing Documentation II
1.1K
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
1.1K
01:14SBAR II: Application of SBAR
4.4K
SBAR is an effective communication tool used by healthcare professionals to communicate patient information accurately. SBAR stands for Situation, Background, Assessment, and Recommendation. For a better understanding, an example is given below.
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
4.4K